attention to the fact that crs has another excellent resource out there, a book also published called "reflective peace-building." it is one of the best pieces of work out there and we use it extensively in our own and turning. it is adopting this perspective as a reflective peace builder. .

i think that one of the things that comes to the forefront is the importance of governance. the research that has been done in looking at countries that are most at risk for violent conflict, the single most important issue that emerges is the importance of governance. countries that are more democratic, more participatory, are generally speaking less at risk for violent contact -- conflict. they do, at the same time, restrict rights and access to information and otherwise control the situation. the most serious autocracies are also less likely to have violence, but for other reasons. what this suggests and one of the reasons we have become particularly important is if you look -- two reasons.

the way in which people are able to resolve their conflicts and range issues about access to water, they are resolved in ways that are seen as transparent through a political process of some kind. the prospects and resorting to violence becomes much more likely. it is that ability to be able to fit -- -- figure out a way to manage that important resource seen as legitimate and effective that is really the critical question. how can we create arrangements to create arrangements -- to create perceptions of water resources that they are the siring access to as manageable. one of the challenges that we particularly face is that if you read this book or look elsewhere

and look at the countries where the water deficit is the most severe and you overlay that with countries in terms of quality of governance, what you see is that the countries where the deficit is the most severe is also the country where the governance is the weakest and conflict, generally speaking, is the most likely happen. we have this conundrum that the places in africa and, to some extent, i am in america, whether we are talking about water basins or arid lands, wells, these are all countries where there is a map. it is provided in the book that looks at this question of oversight. from more of a macro, a global sense, we are faced with a series of problems with certain countries and their overall level of governance as it is there general inability of

fragility that prevents them from being able to manage their water resources and a whole other series of resources as well. the second point i wanted to point out is that water, in most of its forms, can be classified as a common resource, sometimes called a common, and lending itself in the minds of many to the tragedy of commons. it is a tragedy to exploited to the point where it disappears. -- exploit to the point where it disappears -- . -- exploit it to the point where it disappears. i was fortunate to have my ph.d.

adviser at indiana, who was doing remarkable work on this topic that showed clearly that you do not want to move into the tragedy of the commons. you can move into these resources based on conditions that apply. these conditions largely the ball down to the general point where they work effectively and those people that have a stake in that particular resource have the ability to meet together and establish a wills -- establish rules that are perceived as fair, can be enforced, and can be adjudicated. so, essentially it is a miniature governance system that applies to that particularly, and resources. i think that that is a very hopeful sign and argument to be

made that local individuals and groups have in fact been able to manage these resources of effectively if they are provided with the kind of enabling environment that allows them to chief -- allows them to achieve the conditions i just listed. the problem that you run into end with the mayor, running around on the motorcycle and so forth, we could -- quickly find ourselves in environments where we have patron client arrangements where it is more important for high-level people to be seen as taking charge and dispensing favors to the visitor. this is not a kind environment for trying to create the kinds of procedures that need to be put into place for managing full resources effectively, putting a full amount of stress, as there is a relatively overlapping

government arrangement for resources. they are quite challenging to set up. the larger governing process might be in place. that does not mean that it cannot happen, simply that our challenges are there for a fairly severe, coming back to the governance question. the last point i would like to make is that there are certain characteristics of water that are the most unique. one of the most interesting things about that is that it is one of the most valuable resources, river water, resources crossing jurisdictional boundaries between the sea. you might think bed this kind of upstream and downstream conflict would be one that is rife for war and so forth.

one of the things i was intrigued with, the figure early in the document on page 6, providing you with a bar graph of the kinds of issues surrounding trans-boundary river issues. i was intrigued to see that most of them had been positive. one of the things that i think particularly trans-boundary issues around water suggests is that we are all in this together and that it does not seem to provide a focus example of the fact that we need to negotiate and come up with some kind of agreement that allows all of us to have access to these kinds of resources. the fact that we had this success on that scale on these issues, generally speaking are in the area of trans boundary agreements that are held out as

the singular examples of success. otherwise these agreements could have been considered as provoking a complex, and other incidences that led to more general negotiations. [no audio]

>> so, to be effective and do these things, we need to understand these issues and share the inside that we may get with others on these issues and encourage more involvement in these development activities. encourage more working directly with the people to help them achieve their objectives. so, what would we like from this perspective? i would hope that some of this would come out in the questions, although i would not want to tell you which corrections -- which questions to ask. [laughter] where do we go from here? what issues in this area of water conflict investigation need more? where should the development community -- all of us, give

priority? of course, we hope to glean from this, what should we, crs, do do on this critical subject? i will take a few questions at a time, then turn to the panelists to respond to them. yes? >> microphones will be brought to them. >> ok. yes. we have a roving microphone. please identify yourself and your affiliation. >> i wouldn't fight jason to discuss his remarks on privatization. the last time that i looked it was about capitalizing large- scale water projects. what was wrong with the way it was done where you saw it? was that the terms of a contract

bella or did privatization become remedial with problems? i would love to hear the stories. [laughter] >> other question. over here? >> thank you. tony gold, from the usaid program team. i wanted to come to the fence of a former colleague of mine, whose favor you referenced in terms of for analysis and bolivia. working with myself and many others in the world bank, we were very instrumental in including prominent -- poverty assessments as a standard procedure. especially for infrastructure programs. her work has been involved in getting them for it -- voices of the pore expressed.

i just wanted to clarify that. in inside on the privatization issue, the architects of the push, one of the reasons that has been articulated to me that is not widely known, one of the reasons they pushed privatization, stuck in a low ebb of stasis, is in the graph. where there was this quality that was not being over, and there was no conflict associated with that. the poor were not being supported and the privatization push was not being brought to light and moving towards privatisation, which it did, creating the conditions for moving the continuum. i would like to know, from jason's experience in bolivia, since you were there during this

conflict, do you think that there was actually a constructive process? has it resulted in change? if not, what could we have done to make sure that that pushed up the line could have been more constructive? >> thank you. can i take one from the back? yes. >> my name is shannon and i work with the larouche action committee, we always reverenced genesis, that mankind is made in god's image, human beings have the ability to make technological improvements and discoveries to support a larger population and living conditions. one of the key concerns they have is a conflict management. if the assumption is made that water is a scarce resource, we have to figure out how to manage

conflicts. we -- why are we not talking about nuclear power and desalinization? why not talk about modern irrigation? we could greene the deserts' of africa the same way that we did in the united states, not to mention the rest of the solar system. that is my first question. you also talked about political structures, but no one has mentioned the worldwide economic crisis we are in. we are suggesting that we must replace the current economic system that we have but seems to keep the poor poor, and we must based this system on the development of all peoples and technological change. those are my questions. >> let me turn to the panelists, who may or may not be able to enter. who would like to first? >> directly to you, first of

all, i am not an expert on privatization, but i have lived it firsthand. my neighbors have as well. as i understand directly -- correctly, getting beyond stagnant situation, it came to head when a 17-year-old was shot dead by the military sniper. i have seen state entities throw in their who know less about water. that is one extreme. the other extreme is privatization. with the the model, what they showed was very little outside, generally gained through connection fees, raised so high.

this is a high barren area. there was actually pressure on them to use more water. it did not make sense, from a profit maximizing point of view, to run the energy out to the outskirts, because of the abundant water supply at the time of snowcaps, they could not have high water rates. rates were not that expensive, how do you make your money back on the cost of infrastructure? you have to do it through connection fees. they already had multilateral lending. some of the issue is the corruption inside of the entities and breaking free of that.

their alternative proposal, according to shipp was getting the users involved in the governance, having enough of a three-person or four person body, those people can be bought off. if you are looking for people that are interested in the their fellow neighbors instead of themselves, things can happen. the privatization did not work, it was an issue of a lack of water supply. they had no access to international credit for many years, as a punishment. where did these small-scale cooperatives go? we have to be creative and have a balanced perspective. you can say that i am here one way or another, but i am not

blind to the issues. there is something to be said about having the integrity to look at the structure system of the socioeconomic systems of the world. we need to keep working that. otherwise it is simply a band- aid. sorry, i wish i was more articulate. the bicycle story, that is right. the international bicycle event, once per year, going from the classical and moving on to the shores of lake titicaca. we had 200 families that were installed. the funding entity gave $15,000. we got the thing built and we

were still shy $3,000. it sat there for months. we did not have the money for the palm. people were getting frustrated. we did not have the mechanism for changeover. working with public water security was part of the reality. people realize that they would have to leverage in force their hands. that was the day before the event was to pass through the community. it is no fun to get in front of these community members that are livid, you hear on the radio about whether or not your negotiations are going well on the radio. you are able to pull off by midnight. basically to cost sharing. just one of the various incidents we had in my life. >> any other comments from the panel? >> the only thing i would mention is the fact that, if i

have learned anything in my career is the fact that the more complex the problem you are trying to deal with, the presumption is that the solution is also going to have to be complex. it may well be that technology can be a useful factor in terms of trying to resolve these issues, but to think that we are going to invent our way out of these problems, i disagree. i think it we also need to think about how we continue to use the resources that we do have to be good stewards. that is also a part of the responsibility and genesis, this question of agriculture in particular, using a substantial proportion of the water resources. i think that if we are thinking about how we are trying to increase in use technology in

terms of figuring out how we can develop agricultural system that uses water much more efficiently. >> questions? that year. >> thank you. my name is karen with of the nature conservancy. this is like an ideological difference, not so much a conflict. i come from the perspective of how do you bridge the divide between the development agenda and the conservation agenda. we have seen this in the water sector with so much focus on service delivery without long- term sustainability. basically draining off for first. in peru we have been working with our partners on asparagus farms.

a development project that has brought livelihood and income, but only got about 8 feet every year. basically they are these green farms in a desert that will not be there very long. there is not the water to sustain it. how do we bridge the divide between looking at it from a development perspective and from a long-term sustainability perspective? with the water for the world act, how do we get into this notion of watershed protection and conservation as good for people in the long-term and short-term? you have long-term and short- term service delivery if you have them there. let's thank you. another question? -- >> thank you.

another question? >> my name is david ross. we have been involved in developing clean water resources in you gonna after the war closed a lot of their water resources. what is your experience with a conflict in areas and in part with other organizations that could develop resources to avoid future conflicts? de >> next question? >> i would like to thank you for the excellent presentation. one issue, flagging the issue of

interdependence of water with contamination issues for communities and trying to explore, proactively, the prospect of cooperation that could flow from interdependence to solve larger complex. water sanitation might not be the focus of the problem or what got the conflict started. thinking about, and he will be in town next week, the folks at friends of the earth. the good water neighbor program has pared communities around sanitation issues, where kids get sick on both sides of the border and sanitation is not treated, using the logic of interdependence to cooperate and play the cooperation for its own benefit. also using it to improve the relationship of a larger

conflict that at the heart is not a sanitation issue. i think everyone to capture that. as i indicated up front, it is a report that is not just about threats and making the transition to what we do about it, the second point would be in that category of where to, in the future, how do these issues change? the climate changed dimension is a big part of what we have to do. what are the climate change issues, bringing them down to individual implications for a resource sector types. what does it mean for water bellmore in some places, less in others. -- what does it mean for water? more in some places, less in others. a good first step would be doing in part what this report does, in getting folks coming to these issues from different

perspectives. there is an assumption that we know all the languages and tools, mechanisms from learning a lot. i saw there was a lot that we had to learn. i've been have taken up enough time of the presentation. thank you. >> we have some juicy issues to look at. bridging the gap between conservation and the development agenda, the effect on water tables and the people of northern new gone up. the looming question of how climate change affects the work we are doing. who would like to jump into

this? >> heck, i will give it a shot. >> big issues, obviously. i wanted to take on a couple of the issues, possibly in a superficial way. the first starting point, the second thing is looking for the examples of where it has worked. there must be examples, finding them and how they are similar to other situations and how they exist out there. critical when you tried to get to decision makers in the u.s. federal government, showing what kinds of things have worked. in terms of issues of climate

change, obviously a hot topic for many of us these days, what i expect to see in the absence of some very smart intervention and action on the part of various governments and international communities, many places in the world are going to be facing these issues and they have not face these issues before. they are going to be looking at issues where we do not have the governance structure is in place to deal with these things. some of it is already happening in this country. it is important to try to get ahead of those things can begin to think about them, putting strategies in place so that we do not find ourselves dealing with the consequences later on. >> any other comments? >> i am going to pick up on last observation. i think that one of the

strengths of the book is the fact that while there is no question that water has been the object of violent conflicts in the past, there is not necessarily an inherent reason to believe that just because we have a water resources necessary, that it is complicated. i think that that is the importance of bearing that in mind, even as we begin to think about the greater stresses being placed on the water resources. as we experienced a greater warming of the climate, we believe that that will result in issues that have been in front of us before. i think it is important, one of the issues our office has been examining. what are the long-term conflict

implications of global warming? the work that we have commission argues for maintenance of a bit more of a nuanced approach, saying that there are greater risks to deal with, dealing with global warming and other things according to climate models that are having greater impact on countries currently that have little government. on the other hand, let's not discount the abilities of their ability to find ways to manage these changes. one of the abilities we're looking forward that -- looking forward to examining, climb a related change. either of a natural soared as a representative for the asparagus

farm. the question of how it is that communities are adapting and what is predisposing those communities to handling those conflicts by themselves and of what kinds of internal resources and practices, local governments which seem to be a particular use in resolving these conflicts. we think that if we can get that kind of understanding, it will close all in a better place. where are the risks the greatest? there are tensions between development and conservation, conflict and so forth. the only thing that this suggests to us is that we need to look at these issues in a long-term perspective. there may not have been a

conflict with asparagus farmers in the past, but if you tell these people that he will take it away from them, it will become a source of conflict. we do need to be attentive and the only solution is one that looks more effectively at this question of the long-term impacts. of course, this requires us in the development community to take a much more long term perspective when you think about these projects. >> let me take advantage of my role as moderator to try to address the question of you on that. we assess that there are disagreements occurring between communities and regions, but we

do not have a good, systematic way with a way to act on it. after the project is finished so that one can see the evolving dynamic that occurs, we are in a mode of trying to determine what questions we should be asking in these areas. the questions are good, i am sorry, i cannot say that i have the answer, we do not. very few organizations have a good understanding of how to deal with these conflicts. let me give one example. when i was a peace corps volunteer. you do not get to be at the front table unless you are a peace corps volunteer.

[laughter] the department put up a windmill that the interface between two tribal areas in northern tanzania. of course, we had no idea of conflict mitigation for resolution and what it was. conflicts arose between these ethnic groups over who would control the wind mill. they saw the problem their own way. they took it down. the local people took the wind mill down. this is not a method that we would like to recommend for the future. i would call that a catastrophic outcome when conflicts are not understood and addressed. could we get more questions and comments? >> if i could add, on this issue, a good example of a general issue of bringing development activities in these

environments, the only thing that i would add, there is nothing inherent about those posed conflict environments that do not suggest you should do the best you can talk about. it begins with a good assessment and an awareness and commitment to what is the general principle. if you are concerned that it might raise risks, do not do it. do not build the windmill in the first place. but it is possible, generally, if you involve local communities in the discussion of the issues about where to build them and what the issue -- purpose will be, these kinds of efforts, as

we mobilize communities and use resources like a well as a focal point to begin to get conversation, discussion, and reconciliation started, in terms of helping war-torn societies get back on their feet. >> i would like to contact chip and william -- out of like to ask chip and william with their conflict resolution skills, what is the right forum for institution to support for an act of environmental conflict resolution? i am thinking particularly about

trans-boundary issues, where there might not be an appropriate arena for bringing parties together if you think about systems where there are arrangements between neighbors that do not include all of them. different federal states have different responsibilities, finally where institutions themselves might be a part of the problem, which was the case in bolivia for instances where there was serious state corruption. how can they choose a forum or what can be done to enable one where an appropriate institutional setting that does

not exist can be founded? could you say something about how to call or make use of other values in the society that may not be embodied in the particular organization or institution? but would still constitute a shared language or environment for conflict resolution? >> that is a great question. i have become not so much enamored of alerting the

perspectives, we all have them, as noted in the documentation. you need to get in tune before you can engage in the differences. one of the most important things that stakeholders do in the early phases of conflict resolution is figuring out who that person or organization is, if it is institutional. it is really the person that is acceptable that needs these folks. that can involve the kinds of social analysis that is advocated here in the document. in negotiation about the negotiation, it can take time. i know that i and my work with folks, we have spent the time to do that. when necessary. sometimes you have a mediator and it works fine, but there are other times when it is about

trying to figure out who that institutional individual person is, as much as anything else. i urge the taking of time, doing conflict assessment, and knowing that you may not be the person to ultimately serve in that role, but you can help get the stakeholders to a place where they can work on it. >> i do not have anything to add. >> david would be a good person to answer this question, as it is a bit of a set up, he has plenty of answers. on the trans-boundary side, a couple of reflections. one, we should not forget and we should not put it as a lower priority, because the benefits are not as obvious, immediate, and direct as expenditures that

might go directly to a specific project where you can count heads and the people getting access against the millennium development bowl indicator. those things can flow from the investment of processes long term, big states and issues. i think that it is a new travel the question, as pointed out, it is difficult to achieve, but we have bilateral options and multi lateral options. the face forward is constructive. one of the ways in which we can help, solving the problems where it is an instance where it is best done through an intermediary, given the politics of coming in and causing problems for yourself by how it

is perceived. finally, the time lines for supporting these efforts are fundamentally mismatch. so, the example that the banks have for facilitating the initiatives, they say they will give 20 years on the process and they say it up front, as they will not solve it in two years. that is a fantasy, right? if we could get real in terms of understanding what can be achieved, that would be a tremendous step forward. >> comments on this issue? >> referring to the shared values and political dialogue, there are tremendous chances to

have the religious leaders come together with dialogue. softening their shared values. i was glancing at these issues under the catholic social teaching, the right to water in the integrity of creation, as we spoke about earlier. these are, in many ways, core values. these groups have come together. when they see that these groups have had conversations and agreements, that is and it -- a tremendous example of a role model for a community that can move forward. thank you. >> adding a word to that, what would also think that in countries it would also be helpful for the external agencies to stimulate change and understand the motivating values, philosophies, and the

leaves of a culture to bring those forward. the core issues between the people, there are very little issues between them. it may be a lethal in conflicts that may arise. yes, matt? >> my name as colin, from population connection. i want to get to the top of women empowerment and population growth, the idea that there is only so much water on earth and a capacity for how many humans that water can support. that being said, women are usually the ones directly

affected and reading the water -- using the water. there must be solutions in women's empowerment, for example, that can cause controversy itself. so, i wanted to hear your thoughts. thank you. >> another question? yes? >> my name is brother david andrews. i am here representing the food and water watch. thank you for the reference here in the booklet. this booklet has been wonderfully done, it is very complex in handling the issues. one could take catholic, social issues, looking at that section by itself in terms of policy implications, it is made well, but it might include a more robust focus on the right to water, for example.

the last year that i was an adviser to the general assembly in the u.n., there were food and water issues and we saw how impacted the united nations itself was, as a body, trying to implement things like the right to water as a complex -- politically, very challenging. in terms of the on the ground peace building agenda, there are many other issues that one could take out of this by way of advocacy. one, getting the united states to look with a greater appreciation that the right to water. i was wondering, are there other, and finished policy pieces? that if you had a comprehensive

focus, it would indicate that you might like to see it fleshed out more in a future work on water? >> ok, let's address these questions. one of them was on encouraging women's empowerment. another was on the affected population growth and the fact that water was a limited resource. and then there was a question of other policy issues that needed more working out with regards to this issue. hello? >> i will take a crack at the issue. first of all, i notice that we are all white males. i am sure that some of you also notice this as well. in our development efforts, we would try different attempts at

bringing women into the roles. we would always funded drinking water committees. we would gather them after they left. at times we would try different approaches. we would try to use our leverage to enforce it. we would what women of the committees. some of the communities would respond by doing it on paper. others, sometimes we noticed communities closer to urban areas, some of those perhaps traditional values that might not be so -- they're not all cultural aspects of the society. in some communities we found that women have that role. often because there were trusted with the funds. men like succumb to the

temptation to go purchase some beer for their buddies. i cannot say that we came up with a solution, but we always encouraged it. the location of the water stands was always the role of the women, they were the ones who had to go fetch it. on the population issue, i think that we and the church need to look at that as an issue of life. the natural world will, our human life. obviously i am not a bishop, but the fact is that population growth is going to be a huge factor. among others. so, we need to be able to address those issues and i would like to thank crs for addressing these issues that are very difficult. unfortunately, there are no easy answers.

but we need to frame this within the concept of life. a healthy reality and a natural one. >> any other comments? >> i would underscore what you just said on the issue of the agenda. if you accept the general principle that you want to involved in the governance of resources those people making the most use of it, obviously in their roles to the extent that women are involved in keeping the home and providing water for cooking and bathing and so forth, obviously they would need to be involved. of course, it does run into these issues about resources, payments, and the rest of it. if you go into a situation with

the expectation of what you are ultimately trying to understand this who use of the water and how, i think again there is no end to human ingenuity in terms of trying to figure out ways in which you can call those people in those processes. he might have two committees, but i think of the ways are pretty universal in terms of the characteristics of how central women are to resolving this issue. >> i'd like to address the issue based on other policy things that could be done, relating to a question from earlier, having appropriate convening organizations. in a big believer that you need to match the forum to the fuss.

we need a range of options for dealing with these environmental conflict situations. one in particular that came to my attention a while back the really resonated was john mcdonald, who had been working on trying to get the mediation of the environmental conflicts solution at the un. that is not the forum for anything, but it would be an additional option for folks to turn to. >> thank you. we have time for just one more question. if someone has a good, comprehensive question that pulls things together, i would like to hear it. >> this is not a quiz in blood degraded. >> anyone? -- will not be graded. >> anyone? [laughter]

in that case, thank you for being here, you're very presence has shown how important you in your organizations think that water cooperation is. it is critically important and the demand is growing all of the time. we have to find ways to work and share it actively. from this meeting we have taken many good ideas and i hope it will help to nurture our work and, if by some good fortune, you get some ideas that helped you along, that is also very good. with that i would like to thank jeff and his colleagues for the very kind hospitality in hosting this meeting and providing these facilities for us. it has been great and this is a wonderful forum to try to reach out to all of you. i think my colleagues and the

archbishop on the board, as well as the other members that are here. i would like to make particular note of the people that have worked particularly hard on this issue. my colleague, chris, and tom, the senior piece building adviser for crs and the woman from the crs standpoint who put all of this together, to recent held. -- theresa powell. with that, thank you very much. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2010]

>> this is the most requested picture from the national archives, president nixon welcoming elvis presley to the white house. what was the context? we will get the answers today, this evening at 7:00 p.m. on c- span. >> "in fed we trust," from david wessel fed chairman ben bernanke and the role that he played in 2008. "afterwords, ' -- afterwords, '-- afterwords," this weekend of book tv. >> there is limited time left to enter c-span's studentcam

project. enter before midnight, january 20. winning entries will be shown on c-span. do not wait another minute. the 02 studentcam.org for more information. >> now a discussion on long-term health care services. . >> good morning. welcome to this health affairs briefing on our new january 2010 issue, advancing long-term services and support. this is a very special day. this is a very special day. we are very excited about this issue, which is the first full issue of the journal that has ever been devoted to this

particular topic of long-term services. the we are extremely grateful to the foundation which provided us with the funding to execute it. key provisions in key provisions pertaining to this area of long-term services and supports, the largest one being the provisions of the community living provisions or supports act. we will hear later today from one of the key people who made sure that the class was part of

health care reform, connie garner. support for services. we will hear more about those today. the fact that this is the case, that health reform will also include a meaningful long-term care reform is an achievement not to be understated. there is a lot of reforming left to do. there will be even if the other provisions are an active. whether the goal is advancing the quality of care of long- term services and support or providing the most appropriate type of care in the most appropriate setting or providing the most appropriate care for those in nearing the end of life or recruiting and paying a top class, long-term services support to work for or figuring out how to spread the burden of the cost of all this, all of these questions will remain with

us and there will be a lot of work to be done. papers in this issue topple all of the sentence and lay out an agenda for those in the long term care sector as well as for those in government as to how best to proceed. as i have stated, we are very excited about all of this. today marks the debut of the new redesigned of affairs. we have this new redesign and a format for the physical condition of the journal. we also have the early prototype of our redesigned web site, which will be unfolding in its crater cori later this year. we also converted from bimonthly to monthly publications of the hard copy. we have a new logo.

we even have a new motto. we are now at the intersection of health care and health policy. we hope you will take a copy of the redesign journal with you and see for yourself, we have been able to execute. we think you'll find it much more readable, visually interesting, and much more user- friendly than ever before. it maintains the core of the old concept health affairs. i want to introduce you and say thank you to the health affairs staff who are here today, all of whom worked hard to execute the new journal. will you all please stand up and take about? [applause]

-- take a bow? [applause] some of them are actually out in the hall is still working to get this show on the road this morning. i also want to say things in particular to donna abraham who is the lead editor on this issue. thank you very much. i went to thank mary of the university of pennsylvania who be speaking later today for serving as are out urging our outside adviser. i want to say thanks to barry wheeler who helped to engineer the publication of this issue without whom we would not be here. thank you very much. i want to thank the foundation once again for making this issue possible.

i am going to introduce to you the ceo of that foundation. he will make some brief remarks. he comes to us from california. that is where the foundation is headquartered. the mission is to advance the development of a sustainable continuum of care for seniors. it is the second largest foundation in the u.s. focused entirely on improving the quality of health and lives for seniors. before hand, he served as the director and chief medical officer for the los angeles county department of health services. that is after serving for the department's senior all medical director. in earlier he had served as the regional medical director for california health programs for the largest network models that were planned. previously, he worked as an academic internist.

if he is currently adjunct professor of medical at ucla. he served as founding jury of ucla's five-year program. please took me in welcoming him. >> good morning. it is a pleasure to be here. let me first say we are thrilled to see this issue arrived today. it is great to see all of you here. this is a very important in defining moment in how we think about health care and the care of seniors. i want to just begin by thanking susan, her entire team for bringing this issue to fruition. when we had this idea a little more than a year ago, we came to the conclusion that we had this nutty idea. we think you should do a clean issue of long-term services to support it.

it does not seem to be a topic that you guys have covered in a long time. it is not one that you covered in a robust way. from the very first conversation, susan and the team said this is a great topic. it is time. it is something we should give more attention to. we are here today to really celebrate bringing together the leadership that could to give this issue. susan, thank you very much. i want to take the authors and the folks who have helped on the editorial side. many are here today. you all have done a terrific job. many of you have worked on these topics for many years. we are just thrilled to see help of verot create a vehicle and opportunity to bring together your thinking in a comprehensive way.

we are truly at a seminal moment. if you look at where the things that are contained in the house and senate versions of health care reform, and this is not just a bill about standard health care. if you think about where we started out, it to be about coverage and access. that is one of the discussions going on today here in washington. if you look at the bill carefully, the foundation of comprehensive and longer-term service support in this bill. when you look at things like creating an office for the center of innovation. if you look at the proposals, if you did get the ideas around

improving home businesses that the state level taken as a whole, long term services starts with what is in this bill. the stars of health care reform. if one really cares about things like improving quality, creating more care, creating a quality of life and not as tough agenda, and the really important decisions like and in the cost curve -- it is for those who use the system. it is for those most in need for those opportunities. we think that today's issue and the comments that will be made by i by our officers will really be here today. thank you very much. [applause] >> as bruce mentioned, several

authors are also with us today who will not be presenting. it is only because we cannot have a news briefing that was three or four days long. we did not include all the others in this issue. i do want to say a special word of thanks to don taylor of the duke, diane meyer of mount sign a, and all who contribute to the issue. they were healthy to have as with them. long-term care and health care are long-term issues. there also a deeply local and personal issues. we also talked of a national perspective. we want to be conscious that help affairs is very much a local issue. we are very happy to have with us this morning from the d.c. city council, an independent council member of the d.c. council. he was elected in 1997. he headed the committee on

health care for the council. he is also a member of various other council committees including the committee on government operations and the environment. we asked him to come today particularly because he has led dc's effort to make enormous and often ensung inroads into the insurance problem here in washington, d.c. he has begun to take on the long-term services and supports issue. people from washington are as much a citizen of the country as anybody else and a deeply affected by these issues. let me briefly welcome to the podium to make some remarks from a local perspective, councilman catania. >> good morning, everyone. thank you, susan, for that

introduction. this is an issue that is incredibly important to the district of columbia. yet 19 skilled nursing facilities. we have twice as many cmf did deficiencies at the national average. three homes are rate among the worst in the country. this is an area that has long been ignored in the city. we just sent only the quality of care. do you measure quality? how you define efficiencies? a few components we are working on in kansas is a requirement for physician services on the premises. we found [unintelligible] we have found that the first thing that our skilled nursing facilities do is called 9-1-1.

20% if you live in the district, 20% of our pms calls in the city are to our 19 skilled nursing facilities. the average more than one a day. a few of the reforms we are seeking is a physician present at a minimum of 40 hours per week. we are looking at increasing the nurse staffing ratio per patient per day. we are requiring expand its services on our side that include everything from a tie tree to dialysis. -- from podiatry to dialysis. we are making a huge investment in community based care. we have tripled the number of placement of our elderly persons with disabilities labor. we have invested more heavily in

any jurisdiction in the country with community-based care. we have to make sure we reconnect our center with patients who are in nursing @@@@@@fsagh s@ @ @ in other words, we have seen people check in, but they don't check out without aggressive front end and back end discharge planning. we require within 72 hours of admission a comprehensive analysis. if they do not need to be there, we will connect them with our epd waiver. we are looking at being very pro active in making sure that our nursing homes have no way out. if you are in the long term care business, we pay you a hefty wage to take care of our residents. it will no longer be standard

operating procedure as a privilege. with restraint in not only our use of restrictive licenses, but strengthening our petition for receivership so we can actually assume control if we are not satisfied in the way we are operating. a few other items. we are going to be eliminating the use of restraints in the district. we are strengthening family councils and forcing a greater care. we are increasing the standards for our nursing home administrators. we will test competency to make sure you can sit 3 class and absorbent. we are improving the way in which our community whichlbg

community [unintelligible] these are just a few of our items. we have policies of every nursing home. we saw that some had no procedures. what we are undertaking in the district is an effort to be the finest provider of long-term care. we have started this for steps. we thank you. >> as we can see, much remains to be done on why our issue is

so well times. we will begin our first panel which is an overview panel on you is getting and delivering care. some of our audience are encountering these issues for the very first time. we sat -- we strive to set the context. we are going to try to do it today as well. i will introduce our three panelists for our first panel. and then they will get up and presented their remarks. you also have copies of their slides in your packet. we will hear from stephen kay, an adjunct professor at the institute for health and aging and the department of behavioral sciences at the university california's san francisco. he served as co principal investigator at the center for

personal assistance services, which is a rehabilitation training center funded by the national institute on disability. he is also co-director of the university of california at san francisco's disabilities to cystic center and a co principal investigator of the specific ada center. he is a ph.d. -- ph.d. from stanford. we will then hear from carol levine who is with the united hospital fund in new york city. she directs the family health care project which focuses on developing partnerships between health care professionals and family caregivers. she directed the citizens commission on aids in new york city previously. she was senior staff associate of the hastings center.

in 1993, she was awarded the fellowships for her work in aids policy. she edited a book called "always on call." she also co edited a book called "the cultures of caregiving." she has a personal experience with being a family caregiver, having cared for her brain injured husband for a number of years before his death. we will then hear from robyn stone, and the executive director for the center of aging services. since she started the institute 10 years ago, she is developed a number of national programs including the center for medicare education, the better jobs better care of national program.

she was a political appointee during the clinton administration, serving in the department of health and human services. she also was assistant secretary for aging in 1997. she is been a senior researcher for health services research and project hope center for health affairs previously. to begin, but welcome to the podium. let's welcome him to the podium. >> people tend to view long-term care through a particular lands, depending on what they are interested in. some people focus on specific federal programs. they might focus on quality

issues or workforce issues. they also tend to focus on specific populations of elderly. as carol levine said in her article, the whole is often eclipsed by a separate part. this article is an attempt to paint a picture of that hole, although i realize there are plenty of my own biases in it. we include people receiving long-term care from public programs, from family members, from private paid workers, whether they live in the community or institutions, whether they are elderly or of not elderly, whether they are nearing the end of their lives or perhaps have a stable and live on disability.

to do that we analyze data from five national surveys conducted by various federal agencies. for details, see the article which you have that is written -- which was funded by the national institute for research. how many people need long-term care services? that depends on how you define the long term care population. it can arrange all the way up to 11 million people if you include people need help with any kind of routine daily activities. . .

it is well known that women dominate, especially in institutions, where two-thirds are women. you may find it surprising that more than half of the long-term care population is not elderly. despite the fact that the vast majority of people living in institutions are elderly. over half of the long term care population does not elderly, even if you define it narrowly. half of those live near or in poverty. who provide services to people who live in the community?

as you would expect, a person's primary source considers -- varies with their age. parents dominate for adolescents and young adults. by age 30, the spouse becomes the dominant helper, followed by a daughter or a son. more often a daughter and then a son. that holds true until age 75 trade at age 75 spouses start to decline and daughters and sons take their places. only by age 85 do paid helpers are really come into play. as you can see from this chart, and paid helpers' dominate for people of all ages. 9 tons of people needing help

-- 9/10's people needing help get it this way. who pays for long-term care services? that depends on the setting. on the institutional side, medicaid dominates as the pair. usually with a substantial copiague by the resident or his or her family's -- copay by the resident or his or her family's. for others, the resident pays all or most of the bill, which is typically $5,000 a month. medicaid is not a major player on the institutional side except for early in the nursing-home stage. on the non-institutional side,

things are different. you may find it surprising that medicare and medicaid are nearly equal as the players. medicare pays for home health services after a hospital discharge. that sense of being a lot of the it services in the community. often it is the person and his or her family that pays primarily for services. this pays typically last, at $250 per month. if people save money when they are hiring workers themselves by hiring an independent provider which not only saves them money, but gives them more consumer control in contrast to government agencies, nearly always use an agency providers. oops. how much does it cost. in terms of medians, there is a

factor of five, the difference between the two. about $5,000 per month for non- institutional care services. the indians cannot tell the whole story. on this -- medians do not tell the whole story. this shows that base and long- term health services are almost always less expensive than nursing-home services. nursing-home services hardly ever cost less than $3,500 per month. 87% of non-institutional long- term care services cost less than $3,500 a month. these are two very different populations. they are very different populations, but not as different as you think. the average number of daily

activities that people need help with is 3.5, compared to 3.9 for people living in institutions. there are a lot of people with rather severe disabilities in both groups. 40% on the institutional side need help with five or more activities of daily living. they are different, but not as different as you think, and yet you have this factor of 5 ratio and cost. and cost. in terms of national expenditures we're getting an estimate of $147 billion per year. you can add or subtract about $20 billion depending on what you want to include as long-term care vs. not. see the paper for details. more than three-quarters of that is for institutional

services even though those are minority of the total long-term care population. also interesting is the fact that i80% . two elderly who are only a portion of the overall population. let me conclude. this chart shows clearly that we have in the long term system is out of bounds. most money goes to services that hat people do want are often tightly rationed. i think it will be fairly hard to justify the five to one cost ratio when we find that the populations are not that different. we feel that the emphasis on institutional services for the

elderly may end up the nine non- elderly people that need long term services their share of the long-term budget. we also think that there is evidence that most people do not seem to use paid help when they have an alternative. people cannot use paid help as a secondary helper. that turns out to be very rare. we wonder whether these considerations over the woodwork and fact -- effect, we feel that these may be exaggerated. [applause] >> thank you. i am really delighted to be here.

i wanted to thank susan and her staff for working so hard on this beautiful new special issue and the scan foundation as well. i also want to acknowledge david of the united hospital fund. they set the stage very well for this. nearly every discussion of long- term care and services is important. informal care givers, family and friends are the system's back bone or bedrock. like bedrock, family caregivers, that is a term that we prefer to informal. informal sound so casual, so easy, so much fun.

bedrock is underground. bedrock is invisible. when you start to see it, you may be a little bit nervous. that is what is happening in the policy world. we are starting to see these underground workers that are starting to appear and make some demands. families have always played an important role in caring for people that are sick or aging. in the past two decades, family caregiver roles have changed. in addition to funding social support, many are now taking on demanding managerial tasks. managerial tasks are just as hard, if not harder than the actual direct provision of care. family caregivers as a large group are very diverse. some provide a little bit of care, some provide a lot of care. my colleagues are focusing on

this. people with multiple chronic illnesses, multiple medications to manage, frequent hospitalizations, high-cost. at the end of the day, for these caregivers, there is no end of the day. the institute of medicine recognizes in its 2008 report, when it recommended that the definition of the work force be expanded to include family and friends, it also noted that it was not clear how to integrate family into health care practices. one of the purposes of our paper and the campaign which i direct is to demonstrate that it can be done and give examples of how it is being done. there are models out there. let's try this. i am going back. i am sorry.

do you want to get me back to where i was? sorry. next one. go back. one back. sorry. thank you. family caregivers confront fragmented systems. fragmentation exists within the system and even more between systems. providers work mainly in one silo or a sub-silo or sub-sub- silo. caregivers move frequently between their rapid frequent transfers to acute, to sub- acute it to the family settings. we heard that this morning. home and community-based services are sometimes described as a patchwork of different programs with different eligibility rules.

a patchwork suggests individual pieces sewn together to make a whole. community care is often the patches without the connecting thread. to navigate this complicated and still incomplete system come up family caregivers are to provide continuity as advocates and quality sentinels for people who cannot manage on their own. transitional care to next healthcare and long-term services at a critical moment for quality, cost, and outcomes. there are no discharges in transitional care. the handoff is not completed until the patient is under the care of the family caregiver. there are several models like can be shown.

this includes a website, www.nextstepincare.org that is designed to improve relations between hospitals. if it is also organizing an event in new york city in which 40-50 providers will work in partnership to improve the transition and care from our collaborative design group, six months working with 14 providers. our biggest learning was getting people to prevent sending patients back and forth four years. they never talked to them about the process these. they talked about the locations, but not the process these. -- processes.

the transitional care model is one of them at the university of colorado. andy care program at johns hopkins. there are others out there as well. our article concludes with some recommendations. we want to encourage and develop information about caregivers, not just in their psychosocial state and what they do, but how they interact with the health-care system and the social services and how those things could be improved by bringing them together. we believe that working with family caregivers in this current and future environment house to be a core competency for all health care and social service professionals. this is not something that is intuitive and can be caught and -- can be taught and can be

learned. we want full integration of family caregivers and medical homes and transitional care programs, and not just by name only, but by explicit attention to what the family caregivers need. we want to encourage creation of payment schemes which includes the support. policymakers are often moved by family caregivers valuable stories. the story is supported by the practitioners must be translated into specific policy actions which are family caregivers. the health-care provider and policy-makers and join forces with their combined efforts and can be a positive force for better coordination and integration of all of the elements of long-term care

services. [applause] >> good morning, everybody. but also want to thank susan at health affairs, bruce chernof, and all of us collectively for putting together a fabulous volume. it is pretty cool to have the first long-term care services. i said that this was a bastard child and now we are in the forefront. quite only have a few minutes to talk about, what i think it's a very important issue, probably the most important issue in all

of this. if i start with the caveat that the article that i did with mary, to husband around for a long time, we focus primarily on the providers providing services to older adults. that is not to say that there are not other substantial issues for the provider community for persons under the age of 65. most of our work has been done in the area of caring for the elderly. the literature is much stronger in the caring for older adults. there is work and needs to be done caring for the younger populations. i wanted to start with one other comment. that is come up who provides long-term care in many ways it

depends on your definition of long-term care. we will never reach a consensus on this. what we have recognized is that the long-term care, -- a term services and support, formal service sector is somewhat unique, but embedded in the larger health-care sector. somehow, we have to struggle and figure out how to get a enough attention in that part of the service sector that it begins to get parity, not only with other industries, but with the larger health-care sector itself. i will talk about that in a minute. it is important to understand that medicare may not cover a lot of long-term care, but it covers a lot of post acute-care. sometimes we talk about it as

long-term, sometimes we talk about it as acute. whether we want to talk about it as long-term care or not, it is the long-term care providers that frequently have to deal with these issues. next in the family, they are the folks that are embedded in this mess of service providers across the acute, primary, sub-acute, primary, and long-term care sectors. they are really key, next to the family, and holding this fragmented system together. in the long term care sector as opposed to the acute, and primary, and ambulatory care sector, they are primarily the hands-on care system next to the family. at least 70% of all services are provided by your front line. in your personal care workers.

this is different than the acute-care and the primary care world. we have a much heavier a bubble of professional staff. the professional license staff, while fewer, have substantial managerial, clinical oversight and hard-core clinical and support of work that they have to do. these are the medical directors, the lpn's your licensed social workers, and the administrators. workers, and the administrators. as you heard, where the problem with the d.c. nursing homes -- it's the people, stupid. it is the people in these institutions who have not been given the support, training, competency-based orientation and ongoing support to do their work

well. it is very difficult to ask for quality when you have not supported the work force. it is a very labor-intensive and field. one of the most next to hotel industries. not to invest in our workforce and talk about the panacea for quality outcomes without recognizing it is about what people do every day is really a mistake. this is where much of the investment needs to be here. we basically laid out a free mike for assessing reform in the context of long-term care -- lay out a free market. that is with the caveat that long-term care blurs with acute, chronic, preventative care. it is very difficult to pull those out. no. one, we have to look beyond traditional supply and demand the rates which do not work.

has not translated into more money, more investment, and the supply and demand. does not work in long-term care. a lot of the reason for this is that we are heavily dependent on the public sector. unlike other forces of the health sector. almost all of our pay comes from medicaid and medicare. we are dependent on the public hears. what they pay is what we get. -- public payers. what they pay is what we get. our framework argues that we have to recognize the long-term care work force as a distinctive, but related part of the health sector. every time we work on health care reform -- health-care reform, health care work force

reform, it goes towards hospital, ambulatory, and primary care work force. it has been an afterthought. we have seen this with the elder care work force alliance and the others that are happening. specific attention needs to be paid to this long term work force if we are going to develop this over the next 20 years, particularly if we are going to talk about the aging of the baby boomers. we have to be responded to new philosophies and models of care. we cannot do better integrated care without the work force to do it. the social hmo, 25 years ago failed not because they cannot have an integrated system, if it failed because the people to not know how to integrate. it is the people in those models. it is the people that need to be taught and supported and have competencies around that type of

service. it is the people in transitional care. an electronic medical record will never solve our problems in transitions. if it is about the people knowing how to communicate and share information and knowing how to hand off and take responsibility and be accountable. it is about developing that support and those models. it is about developing competencies. if we do not know what a medical director has to do or a social worker has to do or a therapist test to do or a front line caregiver has to do in various settings, how can we expect those people to produce? competence is essential. the implications for a long- term health care work force are essential. we need to expand this. i would argue without the things i talked about before, without the investment, without the

competencies, it is very difficult to expand the supply. nobody wants to go into long- term care. how do we turn that on its head? just as long term care is going to be the economic driver in the 21st century in most communities, that is the sector that is growing the fact -- and to growing the fastest. where are we going to get the work force to do that? investing in work-force development, this is a serious issue. i want to say that we have to make these jobs more competitive. that is not just for the front line, which is an abomination in what we pay our front-line givers. if you look at nurses, if you look at physicians, if you looked at social work, if you did an analysis of the wages and pay and benefit the, there is no clarity across the sector. if you do not make these jobs

more competitive, it will be difficult for us to create the work force that we need. it is the people, stupid. if we want to get the quality, if we want to support economic development in the 21st century, we need to invest in the long term care work force. thanks. [applause] >> thank you, all three of you, for framing these issues in an extraordinarily compelling way. we are going to have some time for q&a for many of you in the audience. i am going to take him moderator's point of asking the first question. as per said it earlier, we have a major provisions of long-term services in the health care legislation assuming the enactment on at least one big

piece. no money goes out the door to support caregiving for five years. we have plenty of leave time to gear up the system that will be able to execute the kind of support that the class act will extend to families. there are other provisions that will kick in sooner. the class act is a compelling goal to shoot for, or least the day in which the dollars actually flow. i want to ask all three of you what you think the nation needs to do in addition of the legislation to get ready for this day. if we begin to think about the initial next steps the policy- makers are quick to have to begin to take so that we have the kind of community-based system in particular as well as

a transitional care system that you can see the opportunity is supported by the formal legislation, where do we start? we will start with you. >> i make the case in our article and i will continue to make the case, that a least in part, it is a short and long term investment in the people that do the caregiving. that concludes if i was going to write an article not our brown family caregiving. the family caregiver what have been included. the family is really the first caregiver. we are starting to see with some of the legislation, so i think it is just the tip of the iceberg, targeted investments in this work force to prepare them and to set a standard for

attracting a pipeline. in the short term, we have to deal but -- with what is, which is incumbent staff and getting people in. in the longer-term, whether it is coming into play in five years when we see the expansion of a need on the older and younger disabilities side, we need to get that pipeline ready. our educational institutions and our investments are so ask backwards in terms of preparing people to do this and supporting them with good wages, good salaries, and good benefits. at least creating a framework for that is important. >> i agree with rob and a lot. -- robyn a lot.

too often that health-care workers can be perceived as, not enemies exactly, but working against each other. they are those absolute essential partners in this. we need to do more to make families and their health care workers work better together. i could never have survived 10 years of caring for my husband at home without the health care workers that i said. in 17 years, i had five people. that is probably some sort of a record. it was not always easy, but we work at yet. -- at it. at all levels we need a recognition, not just in rhetoric, but in reality that the patient is not an isolating -- not isolating an individual

all alone in the world. from every level of service it works as an individual and needs to involve the family to the extent that it is appropriate and possible. we already have two programs that are federally funded. why cannot we put more money into them? a family caregiver support program which is fully under funded. one of the queries on my article, it was 2.5 million for the life span rest but. it seemed too low. it is too low. it is what it is. let's work to deal with but we have and then try to get people

to understand that care coordination and integration of services is not easy. it is not something to say that we can give you more money and do that. we need to figure out how to do it on an operational basis. it is fairly complicated because everything is so fragmented. let's figure out the way that things can be done and make those accountable. this is my personal thanks. why do we not hold hospitals and nursing homes and home care agencies accountable for the medicare regulations and the conditions of participation and that say that you must have a discharge plan in place, you must do this, you must do that. when i talk about having a providers, they looked at me and laughed. poor child, you do not understand.

we do not have time to do that. that is regulations. why do we not make providers more accountable to do that? they just think it is not important. >> i can do a soap box, too. i wanted to say that i think the next policy step is the community choice act. i think the class act is good. it will mean that middle-class people will be encouraged to be prepared to take care of their long-term care needs or at least have been subsidized at some point in the future. as i said, half of the population need long-term care services lives in or near poverty.

i do not think that population is very likely to pay into the program. in any case, a lot of people need services now. as long as the states have optional and not required home and community-based services, they will do what is happening in california and many other states and the times of financial crisis. they will cut programs. they will not cut institutional services because those are required. health care reform is the community first choice option. it is still an option. an option is not enough, at least according to my coat- authors and me. it needs to be mandatory -- co- authors and me. it needs to be mandatory.

it incentivizes states to do this. good. maybe some states will actually do it. it is still optional. >> also want to commend your attention to two other articles in the journal. one is an up close and personal look into the lives of two cult care workers. a piece on the debate over the class act that was written by a founding member. that is an entry point issue which attempts to shine a spotlight on a contemporary policy issues, one that has crept up on the agenda, long after we conceived the issue of health affairs as it is published. let's open it up to questions or comments from those of you in

the audience. please introduce yourself by please introduce yourself by name and affiliation, that would >> i would like to pick up on things that carol and robyn spoke of. i would like to bring the work team work -- the word team work and teams into the discussion. we talk about needing to train the staff at all levels. . els. we need to train the staff and how to do teamwork. the only way we can do care well is through teams. the only ways they make change

depending on the needs of the patient. and maybe informal care working with formal care. we know that these are formal combinations exist in the community. we do not have team work and we cannot train aides to do teamwork. if we do not train nurses to work in teams what they typically pass them in long-term care and to not do much else is the general approach unless it is an unusual place. we need to think about teams and we need to think about training beyond clinical training and in terms of communication and prevention. we need to bring long-term care we need to bring long-term care up into the 21st century and bring hit in to make all of this happen. >> are totally agree with that.

at every lawful we need to understand what is needed and we need to train and support and reimbursed. everything needs to be tied together. right now, the incentives are not in line with a system that we would want. whether it is on the development of the workforce side or frankly, on the split between institutional and home-based services. we definitely need to have a system that supports the concept of teamwork at the individual level as a microcosm for the way that we want the system to work. it is a real systems approach and the training and education that people get, if it does not move in that direction. long-term care more than other areas. it is so inter-disciplinary print -- the disciplinary.

it is a model about how you could build an optimal system. >> what does that mean in terms of the individuals making the systems? >> probably the folks in the room that are from the various disciplines can speak better than high. -- than i. a licensed play nurse is what they call me. most of our training is not in that direction. in addition to that, there is not a focus in specific places in the long-term care sector. it is the notion that somehow by osmosis, the focus on other parts of the sector will somehow translate into the long-term care sector.

there are some competencies that are needed. there are some that are generic. we need to figure out what both of those are. in the under 65 population, there is almost no literature, except some work that has been done on the support worker side. we are a long way from having an educational and training and support system that provides the framework for a system that we keep arguing that we want quality. it always seems crazy to me that if it is sold heavily human capital oriented that you would not have the investment in the human capital and ordered to make that happen. >> another comment. let's take that here. >> this is bob.

you said that the institution can be non-institutionalized had roughly the same needs. that is a quantitative difference. is there a qualitative difference that might require greater services? >> i am sure there is in ways that i cannot tell from the data. i can tell from the fact that certain kinds of interments are more likely to be present in institutional settings. i do not know what in particular that would raise the cost that much, so i have not quite worked that out in my mind. >> some of the costs are room and board costs, which you do not have a community-based setting. some of us have argued that the

act gets to this. we have an entitlement in nursing home care which is an entitlement to room and board services. we do not have a similar entitlement on another side. the failure and growth and assisted living has been that there is no real investment on the room and board side. there is only an investment on the server side in this program. you are not really comparing apples with apples. that is part of the problem. the big chunk of shelter is only addressed on the nursing home side. that is a big part of the cost. if we are going to be honest about this and talk about the community-based infrastructure, we need to talk about the shelter piece of this. we do not put into the cost of what people pay out-of-pocket. their mortgage and their property taxes and whenever.

they are paying for the room and board over their head and then the services are subsidized. we need to get at what the true costs are. >> we will take one final question or comment back here, please. >> thank you so much. i am a dietitian. this is a very exciting issue. and most of the literature that i read, and never see the word dietitian. we deal with people's basic needs. i hope the when you talk about the work force in the future, you will, registered dietitians. i hope that you have a group that focuses on health and aging and there are several hundred dietitians, thousands of dieticians working in long-term care.

we are looking at non-nutrition. we can see when someone is failing to thrive and point that out to the doctors and nurses. we can be a team member. we are dealing with issues. -- term care is not sexy. they note that the agent group is, how do we get entry-level dietitians to come in the golan to something more glamorous? part of that is work-force development. >> we will work on making long- term care sexy and the next edition of health affairs. we will give it a shot. what we have heard on the first panel is that we have a long- term care system of balance. we have heard from carol loving that we have patches in the long term care -- carol levine that

we have patches in the long term care system. if they say that it is the people, stupid. the investment in the people will be the key part and what makes it better. thank you very much to our first panel and to the authors for their contribution. [applause] it is my great pleasure to introduce our next speaker. she is a policy director for disability and special populations for the u.s. committee on health and pensions. she has been the lead democratic staff person, the lead person for the class act designed to help adults with severe functional impairment obtain the services and supports that they need to stay functional and independent. she joined ted kennedy's office in 1996.

if she was the senior policy analyst in the office of the assistant secretary for special education and rehabilitation services at the u.s. department of education. while working up the department, she was the fellow of the coordination for children with disabilities and served as the liaison for the secretary of education and all areas related to help them children, including representing the secretary of health's interests. we are fortunate that we have a new health care reform debate. we are fortunate that long-term care is a part of the debt. we are delighted as all get out to welcome you here today, connie. [applause] >> thank you very much. thank you for making this issue

a priority in this debate around the health-care forum. this is a tough, uphill struggle. i want to thank everyone in the audience who has worked so hard, from a family point of view, to make sure that long-term services and support stays on the agenda for long-term health care reform. i have an article that i wrote. i am here to talk about an idea and a vision that came as a result of a lot of work with senator kennedy that began back in 2003. i will stall a bit of this notion that we had a five-year resting. in the bill. the will give you a little bit of why senator kennedy felt so strongly that this was an important issue. we had a trip up to massachusetts at the end of 2002. we went around to the western

part of the state. we did stop that in number of nursing-home said and assisted living facilities. he came away with a couple of funny things. one is a joke that he told. i am not sure if it is a joke or something that was true. she told me the story as we were dropping into the parking lot of a trip that he had made with one of the presidential candidates are around the state. he got into one of the nursing homes and visited what everybody. when walking up the door, he stopped to talk to three older gentleman who were playing cards at a table towards the front door. i am not sure what he was staring at them for. he did not recognize them. if he said, do you know who i am? he said, no. the lady at the front desk and those who all of us are, she will tell you. he thought that was the funniest

thing. there was not a time that he told that that he did not break into laughter, whether it was 2002 or later on. it was a very high-opening trip for sen. he has -- i opening trip for him. he had watched how important -- eye-opening trip for him. he had watch how important it was. this is the cold core piece of this paradigm as they were trying to put out there as a new idea ted you either have to throw it out there and see how it works or you'll never try it. in the development of the long- in the development of the long- >> we look very carefully at the value of that and the marketability of that. we look very carefully at the

notion that we will never rest until this program is created for long-term care. it will always be called long- term services and support and there is the reason for that. i have a very big personal interest in this not just because of the seven children i have but for the one that i have that is disabled. i know what it is like to not get here until 9:00 3rd it because she has no transportation to work because we did not have the services and support to get her there. i know as a nurse practitioner how important the staffing issue is. robyn is absolutely correct. it goes back to the philosophy of where we are in this country when that it is not the same in european nations and the value system of taking care of your own. the other piece is the educational system. i could remember the very first time in nursing school when you go on different rotations and i went to the nursing home.

the first thing you are hit with is a brand new student nurse sees how awful that rotation is. q your that before you get there. there is not a value on this care delivery. i had been a candy striper in philadelphia before going to nursing school. but it was the only job i was ever fired from. the reason was because i only had sisters. at night, i would fill the water pitchers. i did not know the difference between the water pitcher and the urinal. i felt the urinal with eyes. about 10 minutes later, a her around the screen came out of a gentleman's room. the real nurse went in and saw what happened, she said you cannot do that. man's -- this gentelman's room.

any experience i had in that arena, it was never positive. it was almost like what happens to p e teachers when they get stuck with the special education kids. it is always dp class that the teachers do not want to have -- the pe class that the teachers do not want to have. it was what it had with his mother with rosemary. that was not the way that individuals with disabilities in this country were looked at. on the other hand, he saw his mother struggle and how hard she struggled with the dignity issue. it was not about nursing homes being a bad place, it was about a better trust for her. living out her final days in a place that main memories for

her. everybody in the hospital still wanted to stay there. we drew straws on who wanted to cover christmas eve and christmas day. when you did it, you felt like to make a difference. nobody wants to be there. people want to be home. if it needs to be a continue one that works with what ever is important to that person. we try to develop a model that was a choice model. it was the beginning of a cash model. if people had a choice to do what was important to them, if not was -- what was important to us. the other piece that was very difficult was that we were spending an enormous amount of time on disability and why is it in this country that the number of people that we have with functional limitations, number of people that we -- qualified with people being poor have to

be significantly disable before they can get what they need. why do we have a reverse incentive that this is what we force people into. it does not matter where they are in the continuum of life. if you are poor enough, you can qualify for medicaid. if you are really poor, you can qualify for the nursing-home benefit. why are we doing this? we took it all of the way back. i ask you to think probably about what we do in this country in terms of public policy. if we did what we really do it in terms of forces. i go back into that room and the gerber baby is not the gerber baby anymore. the entire family is turned upside down. what happens when they leave the nursery? but happens when they cannot get an education, a job, a house? what happens to the family we are speaking about?

that young person becomes an older person and they have the same functional limitations. they just happen to be a different age. we set up public systems where you have to be poor, if you have to hide your assets under the mattress. we have to do something with grandma's money. that is when we put people -- what happens when we put people for a general responsibility -- responsible people. the amount of tax dollars is a lie. what happens when the boss does not come anymore? the first day of the school year, up to get a social security flyer. there is not enough support for young people and disabilities to get the job. you are seeing the crisis of a large number of young people who are going to be living with the implications of the autism sector, more than you even know.

we have medicaid and social security and watching tv. these are in addition to the kinds of services and supports that we need. it becomes much more of a medical model. it should blend together. i heard a lot today that deals with the aging population. for this particular piece of the health care, for us, it does not about that. it is about the functional limitations that anybody has. how can you merged this population and the investment populations together so you can create a system that works together. there is not a person in this room that can guarantee what they will look like 24 hours from now. we have not internalize that as a guy you system in this country. that goes from the education that people get, the value where you put your money, and the value and a long-term system.

i had learned what a tough issue this was and continues to be to get on the radar screen for a variety of reasons. it is not global warming. short of dying, this is going to be me perianth this is the heart -- this is going to be me. this is the hardest part of the negotiations. we had to keep it a voluntary nature and try to make it as close to a 401k opt out. how could we make it simple so it was not complicated? you could do a cash model where is your money. it is not the taxpayers' money. it is different than the poverty case model. this is an insurance-based

model. these are the principles, these are the policy objectives. to work with people under 65 as well as over 65. we want that allegedly -- eligibility to be about function. even if it means being in assisted living and having the extra kinds of supports that you need to function in your day there, or in the nursing-home if that happens to be where you need to be. it is not about the perks and the mortar. -- bricks and the mortar. we visited different nursing homes. i talked to the nurse, i would like to see your vending area. we did this in 12 areas. the coax and the diet sodas at work in that machine -- cokes

and the diet sodas in that machine were up $1.50 per can. that was more than the allowance is that people had. . >> there is a difference between the snapshot in time, meaning the amount of time and the amount of selection predicted. the amount of degree of disability that is in these

coring of the act. they took a 2013 snapshot in time and scored it at $75 per day. they took out 75 years and have different variables that they looked at in terms of selection for disability. it is a snapshot in time. what is important to remember about this bill is that we try to construct this in a way that it is flexible enough that the administrator of that can manipulate this triangle to the point that it works well to do two things, maintain solvency, and give a respectable benefit to people. i believe $75 a day is respectable. what is in the bill is that it can never be less than $50 per day and the administration needs to come back with that scale. although you see this is what it

is, it is a reflection -- it is a reflection of that snapshot in time. that is what we have to work with. it is not $50 or 75, it is a range. that is according to the functional limitations and how that model is constructed. it is still to those steps. it is about providing services. that is a big piece. one of the fights we had was family caregivers. good day reimburse their family for the services they provide. that caused a huge uproar. we had discussions at the unions with how to deal with that. we had discussions with members. i can tell you, they're for people who do not understand. and they're not-or dumb but jews

-- but did not just understand. one senator asked why it was so difficult. the other thing is that you are here. you did not know what this is about. he sort of stopped after that. there was a genuine question as to why would you want to pay a family person? they are your family. it is not about paying, it is giving them resources that they would get and other ways in making that system work better. that was not an easy piece to get into this bill. this bill does not allow you to reimburse family caregivers and the thing that is important. if the other people in here is when this rules out, there is a

protection and advocacy piece in here for this. it is controlled by the protection system located in every state's governor's office. that is important so people cannot have an abuse situation. we also did not want to create new stuff. which is not need to develop centers to do the evaluation. this is not about the 5 step process of social security. that is not what this is about. what we need is documentation that you have what you have and you have that functional limitations and a check up to make sure it continues. people ask why that sentence is in there. that is how confident we are that this program will be self- sufficient. it is your money. it does not have strings attached to it.

you see in the bill if you are part of the independent living system, you should use the systems. if you are a part of the aging committee, you should use the aging and disability. we do not want to create new things, we want to use existing mechanisms to pull things together. it is like when i did early intervention for dunker children. i went to delaware because nobody was doing anything. delaware had the highest rate of drugs coming into the coast. they have the highest infant for talented. the highest rate of breast cancer. when i went to the governor's office, i said to make a visit to the house to see the mother that did not have a mammogram. you can print those pieces together. the not reinvent the wheel. use the centers out there already to do this.

robyn is correct about the work force. i remember when i was first about to get my master's degree. i wanted to do long term care for kids. i went to a prestigious university and said that i do not want your track. i want to this different thing. i want to do long-term care of kids with pulmonary disorders. they said it did not make any sense. long-term care is nursing homes and old people. that is not kids. i finally after 80 months got a curriculums put together that recognized that young people with brain tumors really do have long term and import needs. long-term care to not have to be about 65 and older. weaver able to create that. that was the first.

the curriculum's and these nursing schools in terms of being a provider are not there. i asked why there are not special ed students and nurses over there. why do you not hire people. there are several individuals that are functional because of the way society has done things, they get locked into the silos and they are there. i am still working on the governor's office and thinking about that. and it could be a good experience for the students. is another piece that we have not done. another impact is how you could

make a positive change? nobody takes medicare away in this bill. anything you get from this program does not impact your eligibility. that was big. we did not want to go into this poverty model to get with you are paid on your paycheck for. we went that route. if you have four or five adls, you will be at the minimum. >> this page before medicare pays. that is what is fair and works for you. they're still providing q approved over your head --

providing a roof over your head. the second piece is if you access medicaid and you wind up using it and the package of options really includes the tougher things come up those are the big ones. -- assisted technology, transportation, personal assistance. you still need $1,500 to do other things in your house. whatever your acute bonus injury is, this is on top of it. that is how we try to leave

this. the last beasley tried to do is swear senator kennedy had been all wrong. this was never meant to put certain people out of business. we did a lot of exploration as to where this has been our of the last few years and where they are right now. they need a jump-start in order to work. this program is not the end all be all. it is to go together with the long-term care products that are out there. we had the five years in here for a reason. it was to make sure that the government that the participation they needed.

we want to see how many people we have in here before we make promises that we cannot keep. you really need to know what is going on. if you need to pull the plug, -- that is why we have this language in there. we are confident that you have to give it a shot. we believe people will vote for this. what we actually tried to do is say that is what the five years are for. i would be smart about three crafting rapper brand -- wraparound products. there is a lot less risk to me covering the first five years than at the end. i would do it wraparound for

people like connie 117 kids. this will help me all along. at the point where i may be significant, i and -- this will not help me there. they make it so that it is affordable. the question is what happens. there are ways and we will continue to save. we want to work with them. they have increased their market share 25% by doing something like this. that is a new struggle. there are lots of different things you can do. the objections to the bill,

interesting to watch as i look at the whole thing, the obsession with the finance industry. there has been so much focus on financing. half the time you have to wonder if it is financing, because everything is projection. you do not know how many people are going to sign up. he did not know what the degree of disability may look like years from now. it may go down. you do not know what that degree of disability will be. you do not know what the adverse selection rate is. some wondered what happened with the long-term care program. i was told there was people that we thought were going to die did not die.

what ever the projections were about adverse selection had to be a lot different. none of us know about it. until you do it, you will not know the types of the variables that will matter. a lot of focus on the financing model, we wonder what that is about. if you get below the financing and talk about what that 24 hours is like for an individual or what it is like for that individual who significantly has something on the autism spectrum. what is it like for them when they cannot get a fair cuts.

when you get below the financing, you have to think about what it is like. i think people get the little they afraid of that. can you keep a meaningful benefit and keep it solvent long term? that is what we want. adverse selection, you are going to cover everybody? we are going to have episcopal big enough to enjoy that. we do not have the overnight -- overhead cost for this. there are things that you do not need to do.

it attracts the middle-class population because we had the financing peace. we had to get the money for the premium. one population is kids in college. one was to make sure we do something to raise the level of awareness with the young people that you cannot guarantee. you do not know if you are going to hit the front end of that but the board in the sand. -- bookigie board in the sand.

for a parent, it would behoove you to want to pay that premium for them if they cannot pay it themself where pay some of that, because you are in the window where they are not going to get the full protection that you would normally get if something happens. that is a phone call home. it is during the most volatile decades of people's lives. we felt strongly about that. individuals who are under poverty and working.

to i get medicaid or try to continue to work? we gave it to them for $5 for that purpose as well. you have those folks covered on the sand and the middle class people covered as well. we have to see who is in the pool. we have talked to 10 ashbery's. every single one is different. except for one guy who says you need to know all of the projections. all we have to work with its current existing data.

the last issue is to say we felt very strongly that when we talk to parents, grandparents, and young people in school, they think this is important. many of it is tied up in how it is marketed. when i first started with the government's, they had a fair were you son of for your benefits. the flier for long-term care head a woman sitting in a nice garden. that did not register with me at the time. at the flyer as someone who fell off a ski lift in colorado, i may have felt differently about that. this is about you getting a functional limitations not necessarily age related. the marketing of this together

-- it needs to be marketed in a way that a guess the message out. marketing along side of what the other industries are doing. bad as important. we do not want to put anybody out of business. we want to jump-start a flat market. it is not disability insurance. this is money over and above your income. this is not disability.

that is clear. we do not know where the employers are. there is no mandate on employers to contribute. they may want to and they may not. that is how we got where we are. it is a new and different idea. i was with senator kennedy for so long. throughout his life he would call. call. it was >> he realized how important it was that the caregivers were tucked into his house every day and allowed him and got him up

and let him have what was most important to him as he went to the end of his life. they went on that sell boat. it became more of an issue to people when he actually experienced it. the final phone call that i got from him not long before he died within absolute this has to happen. we have to put this into the hands of people so that they have the ability to make choices about how they live and how they died. that is the background of how we got where we are. thank you for having me. [applause] >> it sounds like we have time for questions. >> please identify yourself and affiliation. >> [inaudible]

>> what happens if somebody is in and dropped out and wants to rejoin? it's it advantageous for them since premiums are going up to wait and see if they come down or should they stay in? >> we have any final version of this about what they should look like. some people are very concerned about the system and getting in and getting out. we tightened up a lot in terms of when to kick in, how many years credit you can get. that is all in the works right now.

it was some -- not so much they get to score better, it was more to make sure that programs that are responsible and accountable to the people that are paying into it. if the patient for five years and continue to pay your premiums, can you get out or get in? that was a big problem. we spent some time on that. >> we have a question in the back. >> be a very clear and people being interested in having a systems with peril. in the thoughts about that? >> there is a big piece about

help that is available for family members who are working with someone who cannot do it themselves. there is a big piece in there on that. one of the pieces that we have in their -- who are the people that are going to do the pay -- care? we have asked that when they submit their state plans for medicare, they have to do a survey in their state to get a sense of what is the work force look like based on what they are offering.

i think we will have to pitch in part on that. we really want to help. you need to know who is out there. that is important to community choice. you cannot make the case to the state government unless you say you do not have any people out there. you may not have anybody trained. you need to have that to make the argument to be able to support this stuff. if it will be interesting to see how much resistance we get on this. >> one more question. >> >thanks for coming to speak

here today. i hope we all take a moment to understand this. so much of health care reform [unintelligible] is -- this is the one piece that i think as a transformative quality to it. it brings a new model to the table which is important if we are going to involve. i have a question with that in mind. what can you think are the

strategies to help the long- term insurance industry see the value of this? that is an important piece of the transformation. people change jobs over time. do you have a sense for how managing my benefit kind of a for a one question. -- 401 question. >> that was one of our questions. the other was how to simplify this in a way that an employer does not have to fly, so much data on different people but how to make it more simple.

the easiest way to go is to have a whole the federal plan. there has to be a place for everybody according to kennedy. this could be good or bad. we tried to write it broadly enough. we think it is the better way to do it. there are gap products that are included in the statutory line. i think in all of the stake holders at the table at the very first meeting. the the the but the oversight

should be fine. it is targeting people to say of a. that is my suggestion. >> another is a meeting going on as we speak. what do you think the cuts that it is going to survive the final bill? >> that this tough. don't you have the camera on for me to answer that? the focus is on if you have on one bill but not the other. what we are careful to watch is the structure and the basic

underpinnings from the policy objective does not change. this was not above giving a free-lance ticket to the administration to say crack whatever you want. they have lots of room to move. that is not about here is a ticket to create something new and different. we want to make sure that the contract that is in here does not get pulled apart. there are a lot of providers and people and different groups on board. we will keep a pretty good eye on that. we believe it should go. we believe it will go at the end of the day. hopefully it will be in a form that everybody will benefit from.

kennedy was so clear. if you're going to do health care reform that is not just about acute illness and and triggered if he did not give them what they need to maintain a function and prevent them from slipping backwards, you have not done anything. the long-term care piece is help in our eyes. they are split philosophically if it is a disability bank or a long-term thing. he was cleared to sire if you're going to do health care reform you have to do acute injury and

prevent people from slipping backward. decide what you are doing. i remember that. if we can control it at all, it will be she -- it will be in. >> i have a feeling that when we are in that place where we hope there is a lady at the front desk that remember our name, there'll be a lot of people out there who will remember yours. thanks very much. [applause] we are going to adjourn for a quick 50 minute break. we'll be back here in 50 minutes

for our next panel on)& >> you are watching c-span, presented as a public service. here is what is ahead. next, preston obama announces an education initiative followed by today's white house briefing. chris dodd announces his retirement. later, governor patterson kids the new york state assembly and address. -- gives the new york state assembly an address. >> this is the most requested photograph from the national archives. what were the circumstances behind this photograph?

what was it like to be in the room when this was taken? we will get some of those answers tonight at 7:00 eastern. watch that live from the national archives this evening here on c-span. >> the new video library is a digital archive of c-span programming from barack obama to ronald reagan and everybody in between. over 157,000 hours of video are available for you. it is fast and free. try it out at c-span.org. >> i am always concerned about unintended consequences and regulations. they act as a tax. we have to regulate something, we tend to get less of that. >> this weekend, the fcc commissioner on efforts to create a national broadband

plan, next neutrality and other issues. >> president obama announced earlier today that $250 million for math and science teacher training. he addressed an audience of math and science teachers from across the country. this is about 15 minutes. [applause] >> ladies and gentlemen, to introduce the president, please welcome miss barbara stockland. [applause] >> i cannot contemplate my career as a teacher without reflecting on my dad.

i was not born when he was a student but his marginal education helped form my teachings. he was from a poor farm family and although his parents loved him, sometimes they worried more about how they're going to clothe and feed him then about how well he could read or write. his expectations were low and he met that standard. when the energy crisis hit in the 1970's, my father tackled it like a math problem. and said picking up the paper and pencil, he talked his way through it. he thought outside the box. he built an electric car of a used volkswagen parts with a wind generator he built from scratch. he was able to do that in spite of the fact he did not learn it in school. .. .

in some ways, the disconnect between what my dad needed at home and a disconnect -- and what he learned at school lives on in america. as teachers in the 21st century, we are experiencing a paradigm shift as we consider what we are teaching is relevant and whether it is engaging. our focus is shifting to bring out the true lerner and our students, because within their lifetimes, their ability to learn will surpass their need to know. although many aspects of our profession are changing, many remain the same. we still wear many hats each day -- coach, finder of lost articles, substitute parent, a sales professional, and keeper of the faith. we are the most fortunate of all labor. each day, parents and trust us with their greatest gift -- their children. as teachers, we have a past that

is rich in memory, a present that is rewarding, adventures, fun and challenging, because we spend our days with the future. and now, it is with great honor that i introduce to you a man whose lessons extend far beyond the classroom walls, who is writing history, modeling of present that is challenging and venturing, but hopefully, a little rewarding and fine, who is helping to shape the future for all of us -- president barack obama. [applause] >>thank you. thank you, everybody. please have a seat. thank you. well, it is wonderful to be here. barbara, thank you for the outstanding introduction. i want to acknowledge a few other special guests that we have here. first of all, my terrific vice

president, mainly because he takes orders from dr. jill biden. [laughter] dr. jill biden and vice president joe biden are here. [applause] somebody -- i've never met somebody who's more passionate about making sure that young people do well than my secretary of education, arne duncan. arne duncan. my -- before i won a nobel peace prize, this guy had won it, and nobody questioned whether he deserved it or not -- my secretary of energy steven chu. three wonderful members of congress who have devoted a lot of energy to the issue of science and math education; i want to acknowledge them --

representative bart gordon, who is the chairman of the science and technology committee, democrat from tennessee. where's bart? there he is. thank you, bart. representative william lacy clay, from the great state of missouri -- and his district is home to two teachers who are being honored here today, so he's very proud of them. and a great champion of education generally, he's the chairman of the education and labor committee, representative george miller of california is in the house. we also -- since so many people were inspired in this country originally from our space program to think about math and science in new ways, it's terrific to have our nasa administrator and former astronaut charles bolden in the house.

we've got regina dugan, who is the director of the defense advanced research projects agency, or darpa, as many of you know. we can thank them for the internet and all kinds of other stuff. so please give regina a big round of applause. and our national science foundation director, arden bement is here. thank you so much, arden. now, most importantly, to all the teachers who are here, as president, i am just thrilled to welcome you, teachers and mentors, to the white house, because i believe so strongly in the work that you do. and as i mentioned to some of you, because i've got two girls upstairs with math tests coming up, i figure that a little extra help from the best of the best couldn't hurt.

so you're going to have assignments after this. [laughter] these awards were not free. we are here today to honor teachers and mentors like barb who are upholding their responsibility not just to the young people who they teach but to our country by inspiring and educating a new generation in math and science. but we're also here because this responsibility can't be theirs alone. all of us have a role to play in building an education system that is worthy of our children and ready to help us seize the opportunities and meet the challenges of the 21st century. whether it's improving our health or harnessing clean energy, protecting our security or succeeding in the global economy, our future depends on reaffirming america's role as the world's engine of scientific discovery and technological innovation. and that leadership tomorrow

depends on how we educate our students today, especially in math, science, technology, and engineering. but despite the importance of education in these subjects, we have to admit we are right now being outpaced by our competitors. one assessment shows american 15-year-olds now ranked 21st in science and 25th in math when compared to their peers around the world. think about that -- 21st and 25th. that's not acceptable. and year after year the gap between the number of teachers we have and the number of teachers we need in these areas is widening. the shortfall is projected to climb past a quarter of a million teachers in the next five years -- and that gap is most pronounced in predominately poor and minority schools. and meanwhile, other nations are stepping up -- a fact that was plain to see when i visited asia at the end of last year.

the president of south korea and i were having lunch, and i asked him, what's the biggest education challenge that you have? he told me his biggest challenge in education wasn't budget holes, it wasn't crumbling schools -- it was that the parents were too demanding. he has had to import thousands of foreign teachers because parents insisted on english language training in elementary school. the mayor of shanghai, china, a city of over 20 million people told me that even in such a large city, they had no problem recruiting teachers, in whatever subjects because teaching is revered and the pay scales are comparable to professions like doctors. so make no mistake, our future is on the line. the nation that out-education us

today will out-compete us tomorrow. that is not acceptable to me, and i know that is not acceptable to any of you. that is why my administration has set a clear goal -- to move from the middle to the top of the pack in science and math education over the next decade. to reach this goal, we have paid particular attention to how we can better prepare and support, reward and retain good teachers. so the recovery act included the largest investments in education by the federal government in history, while preventing more than 300,000 teachers and school workers from being fired because of state budget shortfalls. the department of education will announce an initial $10 million in grants -- for young person embarking on her first career or a scientist or engineer starting

her second. under the outstanding leadership of arne duncan, we have launched a $4 billion it raced to the top fund, one of the largest investments in education in history. states are competing for finding and producing the most innovative programs in science and math will be an advantage in this competition. as well allowing scientists and statisticians and engineers to more easily become teachers. we want states and school districts to start being more creative about how they can attract more science and math teachers. we are also pursuing reforms to better serve america's math and science teachers so that each and every one can be as effective as the educators we are today. we are challenging states to raise standards, to use data to better informed decisions, to recruit and retain more good teachers and to promote stronger curriculum of that encourage young people to not only learn

the facts and a text book but to explore and discover the world around them. as important as this will be, the success we seek will not be attained by government alone. that is why i have challenged the scientific community to think of new and creative ways to engage on people in their fields. that is why we launched the educate to innovate campaign, a nationwide effort by citizens, not profits, universities and companies from across america to help us move to the top of the pack in math and science education. today, we are expanding this campaign. several new public-private partnerships are going to offer additional training for more than 100,000 teachers and prepare more than 10,000 new teachers in the next five years alone. through the partnerships we are announcing today, support for the educated in of a campaign has doubled to more than half a billion dollars in private funding. that is a figure that we only

expect to grow. to help educators already in the classroom, intel is launching a 10-year campaign it to train at and science teachers in all 50 states to better use new technologies and techniques and a lesson plans. pbs and the national science teachers association will also create a new online platform so science and math teachers can share best practices and learn from one another. to bring more educators into the classroom, a national math and science initiative is working with texas instruments and the delaware foundation to prepare almost 5000 new math and science teachers in the next five years through a program that allows young people to earn a teaching certificates and science degrees at the same time. the presidents of more than 75 of the largest public institutions in the countries have committed to introduce thousands of additional math and

science teachers at their institutions. and the woodrow wilson national fellowship foundation is expanding to place more math and science teachers in more high- need schools. just because you are not a teacher, that does not mean you cannot help educate our young people. we need look no further than the mentors we honor today. i am calling on all 200,000 scientists who work for the federal government to do their part in the gut -- in the community, to speak at schools, to efforts like national lab day and help step that same curiosity in students which perhaps led them to pursue a career in science and the first place. nestle also be launching an enrichment program -- nasa will be launching an enrichment program and to bring students to nasa so they may experience that same wonder and excitement. as president, i will try to do my part. we have helped -- we have held

astronomy night here at the white house. that was very fond, by the way. -- very fun, by the way. we are planning an annual science fair. secretary duncan and i will be working to promote the teaching profession it, to show young people that teaching is one of the best and most rewarding ways to serve our country. and we are recognizing the folks in this room with awards for excellence in teaching and mentoring. it is with these men and women that i would like to conclude today. because, in the end, the work that you do and the difference you make our what all of these reforms are all about. whether it is showing students how to record the habits of a resident reptiles or teaching kids to test soil samples on a class trip to costa rica, whether it is helping people from tough neighborhoods in chicago to become a junior paleontologists or creating a

mentoring program that connects engineering students with minorities who are traditionally underserved in the field, all of you are demonstrating what teaching is so important and why we have to support you, the quick view and send in reinforcements for you. -- and equip you. every person in this remembers a teacher from a difference in their lives. they remember a moment in which an educator show them something about the world or something about themselves that change their lives. it could be a word of encouragement, a helping hand, a lesson that sparked a question that ignited a passion and ultimately may have propelled a career. innovators, folks like michael dell who are here today, are made in those moments. scientists and engineers are made in those moments. doctors and teachers are made in those moments. the small interactions. so, yes, improving our schools is about training and new generation of workers in new

industries, but a good education, provided with the help of great teachers, is about something more. it is about instilling in a young person a love of learning and a sense of possibility in their own lives, and understanding of the world around them that will serve them no matter what they do. that is what we have to do as a nation. that is what all of you do every day. and that is what will lead to greater opportunities and bright horizons for the next generation and for generations to come. so, thank you very much everybody in. congratulations. [applause]

>> now today's white house briefing. they announced they will release an unclassified report on the christmas day bombing attempt on flight 253. robert gibbs talked about that and other issues. this is almost 50 minutes. >> come up here. shoulld we start? does ap have a couple questions on reid's beard?

she was in hawaii for two weeks. let's get back -- he was in hawaii for two weeks. mr. feller. >> two topics, on the senator dodd's retirement. what is the president's reaction and has he spoken to the senator? >> i do not have the readouts, -- on both senators dodd and dorgan this morning. senator dodd has been enormously involved been enormously helpful in moving both health care and financial regulatory reform. working on those issues and moving them through congress. the president has a great fondness for senator dodd and for his work over 30 years in the united states senate. >> democrats will not defend four open seats in the senate. and as you know, the white house

has had to fight for every one of the combined seats to keep the majority. how do think these requirements will affect the president's --? >> it is hard to look into the crystal ball to 11 months from election day. there is requirements on both sides. there will be the same and the house and the senate. we will let the political season play out over the course of the next 11 months i do not -- i do not want to make a lot of predictions for 11 months from now. >> i want to ask about terrorism. we know from what the president said, that the brenman report will be released soon. >> i anticipate it will be released tomorrow. >> the public one? >> it will be an unclassified version of what john brennan it gives to the president.

sometime probably early afternoon. and then our hope is to bring it john down here and go through it. >> the president also said that he will be announcing more steps on passenger screening and intelligence. do you expect that this week? >> we will check on that part of the schedule or whether that is part of tomorrow's information. but i do expect at least at the beginning part of that to happen tomorrow. >> what i am getting at is, can you give us a sense of how this is all going to finish? will there be a final review and the president will speak to the nation again? >> the president will make a statement about this tomorrow. that review will be released -- the unclassified version will be released publicly. we will have a john and probably secretary janet napolitano to discuss their view of detection

capabilities tomorrow here at the white house. i anticipate that the president and john will continue to look at the situation and evaluate it over the coming months. the review will simply identify and make recommendations as to what was lacking and what needs to be strengthened. the review process will be economic one of where the president and john will continue -- it will be a day gnynamic on, where they will implement their plans for what was identified in those reviews. in yesterday's meeting, each agency and department took responsibility for their aspect of that systemic failure. each belt lined what they had -- each outlined what they identified as shortcomings and ideas for changing those.

the president will be anxious to watch that and john will watch that and follow up with each agency as it transpires. >> i wanted to clarify something and ask the question. he said the review will be released tomorrow. >> yes. >> going back to senator dodd, how do think it will affect financial regulatory reform, because he has been a leader in that? in writ -- on wall street, some stocks have gone up. >> as is the wont of wall street. i think senator dodd has spent a passionate advocate for insuring we have rules in place so that what happened on wall street does not happen again. the we have strong consumer financial projections -- that we have strong consumer financial projections.

-- protections. >> will that make him more of a lame duck? it is a loss of that passionate advocate. >> no, knowing senator dodd, and the passion advocate that he is, i think he will continue to work hard in want to get this done by the end of the year, as the president does, too. >> the president last year set a deadline for the end of 2009 and for iran to begin showing some compliance with the international agencies when it comes to its nuclear program. has there ben that any movement? if not,-- by the iranians that we do not know about, and if not, what is the next up? >> the next up is ongoing, and that is working with our partners in the pf plu5 plus one

and the international community and looking at the neck steps to hold iran's accountable. we have said and made clear throughout this process that they should act and demonstrate living up to their responsibilities. that failure to act would result in consequences, and we are in the process of, as you heard the president discussed, developing what those consequences of our with our international partners. i would say, and you've heard the president speak on this now, both in oslo and over the christmas break, we have noticed continued divisions within iran, including much greater calls for universal rights and universal values. and we are watching this closely. >> should we as fact that when

nations reconvene, the united states will push for economic sanctions? >> i think that working with our partners and working throughout the international community, we will take steps to develop what those consequences are. >> when the un reconvenes? >> i do not know the exact date, but that would be the understanding that we had begun even before the end of the year initial discussions both within the administration on what can be done as well as with our international partners. >> i want to follow up on the comment the president made before he went to hawaii. i forget. whether it waas with nps or pbs.. she was asked whether and minority in the senate had been invoking cloture more than before.

he was asked what could be done about it. one would require 67 votes, which we do not have. one would be a reverse nuclear option which might cause damage to the senate. another is a bill offered by senator harkin would offer a sliding scale for cloture. especially with facing the prospect of losing seats in the senate in 2010, for at the very least a wash, but nobody predicts that you guys will gain any, is there any support by the president for any of the measures to change the rules so that he can have an easier time getting -- ? >> i have not heard of any discussion. i will check with legislative affairs. i have not discussion about support for changing roles. i know senator harkin's bill has been talked about for some

time, going back to some traditional disputes that were had not too long ago. i think the president's overriding frustration has banneen, i mentioned this yesterday in dealing with personnel aspects, it is not simply that you see tactics purely to delay, purely to watch the clock winds around and around, but they do not even appear to be philosophical. when something gets filibustered, and we take 30 hours to debate it, and the ultimate vote is 88-10, was the filibuster predicated on anything else other than watching the clock wind around? it is not a philosophical -- philosophical argument. it is just an argument, i suppose, to hear people talk in

order to delay the passage of a vital legislation for the american people. i think the american people would be frustrated and are frustrated by the lack of not getting anything done just to hear somebody talk. >> liberal activists want you guys to do something about it. are you not going to? >> i will check with legislative affairs. i have not heard anything. >> guest today, the president talked about red flags -- yesterday, its and pieces of information the intelligence community had, that it involved someone we now know to be the suspect. was this specific information that was tied to an airliner, anything like that? or was it more general? >> we will wait for the review to come, the public portion of the review to come out. john will be able to speak in

depth about those issues. to reiterate what the president said, the top line message he had was we understand this was a systemic failure. information we had in our possession, information that likely could have prevented or disrupted the incident on december 25 from happening. the president is anxious, and it did so yesterday for almost two hours with his national security and intelligence teams, both through -- go through questions about how we got to this point and steps we are going to take going for. something like this, based on what we had during that meeting. >> is there more there? >> i think the president has been very candid about the fact that what we were in possession of it in different places and what ultimately was not analyzed

up through the chain's in order to make the necessary connections to prevent and disrupt this. >> negotiations taking place to meld these two bills, the house and senate, why not have a formal conference? >> that is a question i think you can ask the leaders in congress. either there or when they are here later today. >> why did the president dropped the ball on health care? he is ready to accept anything to get it over with. >> i would disagree, helen. i think the president laid out in front of congress some very clear benchmarks that have to be met in order for health care reform -- the promise that he outlined in that speech.

we are in the process of working with congress to iron out the small number of differences between the two pieces of legislation. >> you are not allowing the government plan even to be considered. >> that is in one bill and not the other. nothing can get connected unless or until it gets both houses. >> the president can weigh in on it. you are getting a 30 million new plans to the new insurers. it is a bonanza. >> in return, we are getting vital insurance protections against preexisting conditions, against lifetime caps on health care. i think the net winner by far in this process will be, not simply those who have lacked accessibility to health care, but those and what have access

but have struggled with insurers. >> the bill outlines the different waves that -- and aspects is paid for. it is completely paid for as the cbo mentioned. >> during the campaign, the president on numerous occasions said words to the effect of all of this will be done on c-span in front of the public. do you agree that the president is breaking an explicit campaign promise? >> we covered this yesterday, and i would refer you to yesterday's transcript. the answer i would give today is similar to the one -- >> there was an intervening meeting with the president pressed the leaders in congress to take the fast track approach, to skip the conference committee. >> the bill was to get -- the president was to get a bill as quickly as possible. i would refer to what we talked about yesterday. >> the president in this meeting

yesterday pressed for something in direct violation he made during the campaign. >> and i addressed that yesterday. >> would it be more helpful at this process or more transparent? >> how many stories do think they have done on this? just a guess. >> my question is whether he broke an explicit campaign promise. that has nothing to do with it. idea with information, how much or little of it is. would people benefit from having more information? >> do you lack information? do you think your reported stuff that is inaccurate? >> -- the process that is being employed in health care. >> we had this discussion yesterday. i answered it yesterday. and he will do so today. >> does the president -- has the president expressed a preference on the approach to pay for reform.

? taxing the cadillac plans or taxing millionaire plans? >> we will discuss that. i have not heard a way definitively. >> did anyone here at the white house suggest to senator dodd either directly or through an intermediary that he should consider -- >> i think you heard senator dodd say in thinking through this, he made a decision based on a lot of different things in his life and came to the decision that it was time to step aside. >> looking into a crystal ball, looking ahead, but senator dodd he is facing the toughest political environment he has ever seen. i wonder what responsibility does the president feel he and his agenda have in the political environment that democrats are now facing, and are making very

difficult decisions about their futures? >> the president has made conscious decisions about his agenda, but at the same time, jonathan, we are dealing with a set of issues, whether it is the financial collapse, whether it is a 10% unemployment, whether it is decisions on auto companies that it -- afghanistan, terrorism. those are decisions that the president has had to make in a very tough political environment. the president understands that. he did not sign up for the easy part of the job. he signed up for the job. if you look at, obviously the president has a great fondness for senator dodd and for his work. i do think a number of decisions

were made on an individual basis about whether or not to continue running for reelection or in running and the first place. i fail to see a commonality or common thread that goes through each and every retirement. >> do you think that the president bush for such -- pres dident's push for such big items so fast has contributed to this environment? >> he is dealing with a full set of crises that he had when he came in. he understands that. he had to make tough decisions that may not be politically popular, because that is what he was faced with. again, that is why he ran for the job. that is why he decided to throw

this have in the ring. -- his hat in the ring. there are very few easy decisions. the president believes we are on the road to a publishing quite a bit. i think we have taken it tough actions to stimulate our economy, to ensure our financial system did not collapse, to ensure that our auto companies did not go bankrupt and out of business costing tens of thousands of people to lose their jobs. none of that may have been individually politically popular, but i think if you look at where we have been on the jobs front in january, 2009, and where we were in the reported november, 2009. we have gone from losing 700,000 jobs a month to losing 11,000 jobs per month. we are not where we want to

be, but we are better than we work. the fifth quarter had positive economic growth. >> has the president talked to secretary salazar about his future? does he want to keep the secretary in the cabinet? >> i think secretary salazar is a friend of the president's that came to the senate at the same time. we think he is doing a viable work. he has not had a conversation with him recently about politics. >> you are enunciating it could be a platform for a midterm campaign. how much do think the president is. to be out there campaigning for people in his party? >> i think he will weigh in. we have done our part in raising some funds for candidates for the democratic party.

i suspect that will continue. i have seen it -- i have not seen a detailed plan of what happens 11 months from now. >> go back to review that they are going to announce tomorrow. can you give us some sense as to just generally what issues this thing is going to cover? you have this review and then the final review. maybe there will be an interim review. how far as this one going to go, addressing human and systemic failures? >> this will be very comprehensive. the president the preliminary assessments a little more than a week ago from virtually every agency, the cia's came in a few days after that, detailing what had gone wrong. john brennan synthesized a lot of that.

they walked through a decent portion of that yesterday in the situation room. the president got a very detailed look yesterday at what john has found in terms of -- his portfolio was on watch listing. it is, in a sense, broader than watch listing, because information that would lead you to be watched-listed is what he examined. secretary napolitano looked through overcharge -- her charge was about detection capabilities and screening. we have taken actions in the interim to increase their security, both at airports here and for flights coming into this country. i think john's report -- his report yesterday was very detailed, very comprehensive. >> will it be even more detailed on the watch listing? >> in many ways, this will be

the close of this part of the investigation as to the 25th. what i alluded to the dynamic of looking -- continuing to look, the president and john brennan will be -- the president believes we simply cannot identify what we were doing on the 25th and what we have to do different thly. will want to continue to look at what -- the progress of what has been identified, whether we are making progress in meeting those necessary changes. i do not have a time line at the moment for that. but i think john's report to the president has spent enormously detailed. >> any personnel announcements? >> not that i know of. >> change of subject.

there is reported out of the pentagon today that says there is one and five guantanamo detainees upon their release return to terrorism, which is up from a previous pentagon report on this subject. what was the linkage of that to the suspension of transfer of detainees in yemen yesterday? >> i have not seen or heard about this latest report you refer to. and i do not have can do what numbers have been at for similar reports in it years past. yesterday's determination was made and announced a very much on what you heard john brennan say over the weekend. we never have a plan to transfer anybody to their home country or a third country that we believe,

we have reason to believe it will present a security situation for us or for that country. in relating to yemen, i think you heard john say nobody was going to be transferred back that we did not believe that government could handle. the determination was made that, given it, as you heard the president say, the swift change in the security environment even over the last few weeks in yemen, caused the president and the attorney general to agree that pausing those transfers was the right policy right now. >> does recidivism have any bearing? >> let me get a better answer from nsc based on this report. >> does it make it harder to

close guantanamo? >> i think you heard the president said yesterday we are committed to close in guantanamo. -- closing guantanamo. you heard the president in enunciate clearly that one of the explicit reasons mentioned in very early recording material from al qaeda in the arabian peninsula was the existence of guantanamo bay. that having been said, as john and others have said, on numerous occasions, we are not going to make decisions we believe threaten the security of the country. >> are there any you are proposing? >> now that i'm aware of. >> can you assure the traveling public that all -- airlines is protected? >> i am going to push you to tsa

on specific airline security procedures to get a better picture. >> are they doing anything to protect the travelling public on trains and metro? >> let me check with d.o.d. on that. -- dot on that. without getting into specifics, i think there is a heightened awareness across government. >> is it fair to say that the policy referred to is an indefinite pause for a substantial period of time? >> i forget the exact phrasing the president used, but i would say into we believe the time is right. >> when the president referred to the security situation in yemen, are you referring to the ongoing conflict that is described as a civil war, or are you talked about -- talking about their government efforts against al qaeda? >> one has been going on for quite some time. the al qaeda efforts have started more recently.

that is what i would like to know. >> um, let me try to phrase this. there has been a security situation. this has not been is a part of the world for quite some time. what i think you heard the president referred to, without getting overly specific, just within the past couple of weeks, we have seen a far different security situation. >> i am trying to understand the linkage with that and the necessary decision to cause the transfers. is that stepped-up efforts against al qaeda make it more difficult for the government to provide the security necessary to hold detainees? >> i think i see where you are going. i would not draw that direct linkage, but i would say that as john said last sunday, we never

had a plan to transfer yemenis back to their country if it their government was not capable of handling that transfer. >> that should be what we should assume now. for various reasons, they are not capable of handling transfers. >> for a number of reasons we have decided to make the policy decision. >> on iran, you say the next that is ongoing? >> how was that complicated by the chinese ambassador that now is not the time for sanctions at all? should we discuss diplomacy -- diplomacy and continue dialogue with iran it must take precedence? >> we have discussed with the chinese. the notion we are not in discussions with the p5 plus one. i am not sure he used the word

discuss. >> that is not the right moment for sanctions because diplomatic -- corps on going. >> i am not sure she mentioned -- used discussions. we have been in discussions with the chinese, the russians and our partners as well as in international efforts involving the iaee and others to discuss the nuclear capability of iran. obviously, there are countries that have always had varying degrees of interest in the timing of different consequences. we understand that. we are working with folks in order to bring them along on this pack. >> to follow up on the conversation yesterday about openness and transparency, do you believe that the standard the present described in the campaign has been met as regards

to health care? >> i think you passed this yesterday and my answer yesterday was yes. again, i have turned on any number of television's and open to any number of publications and seen health care discussed quite broadly spurred >> when she was asked about this speaker pelosi said there were a number of things he was for on the campaign trail, suggesting that she thinks that perhaps this campaign promise is not being met. aides went on to say she is referring to the president's declaration he would not raise taxes on those making less than $ 250,000. she maintains that the tax on cadillac plans violates that promise. >> as you know, in a transparency of network and network -- and cable television, you would explain to your viewers that any cadillac taxes on in inshore for offering a plan that exceeds $239000.

we can add to the open is right now by having that discussion. -- exceeds $23,000. i disagree with your notion that it is a tax on an individual sense as opposed to a tax on insurance company that offers a plan. in terms of speaker pelosi, all involved thought the meeting they had was a very productive. >> you do not think they passed those taxes, those costs onto consumers? >> i am not in insurance company broker. >> it is obvious. >> not necessarily. >> they were considered a defect code taxpayers >> are you speaking for economists? >> it is self-evident. >> you said yesterday, i do not believe anyone has legitimate

constitutional concerns about health care legislation. is that from the counsel's office? >> nobody has done an analysis. >> to have something substantive it from a constitutional point of view? >> i do not believe anybody has looked at it, because i do not believe anybody believes it is unconstitutional. >> the announcement tomorrow -- peter king on the morning talk shows saying that -- the president describes somebody should go and the president's review. has he seen anything requires disciplinary offense? >> when you talk to john, marked in a report tomorrow, it was not falling down of one agency, department or one person. this, as the president described, was a systemic failure. each of those agencies and

departments yesterday took responsibility. they outlined plans for filling the gaps that they found. i do not know what the final outcome, in terms of hiring and firing will be. i know the president is focused, because of the broadness of what he believes the broadness and systemic nature of that failure is, to find those polls and fill them. >> he does not envision someone's losing their job? >> i do not think any final decisions have been made. you will see tomorrow that this is a failure that touches across the full waterfront of our intelligence agencies. >> -- it is still a possibility,

just not part of tomorrow? >> i doubt it will be part of tomorrow. >> doesn't reflect advice or decision on how to prosecute -- doesn't reflect a decision on how to prosecute in terms of the civilian courts? >> will that be part of the review? >> not that i am aware of. that was not part of the direct review. they discussed this yesterday. we discussed this on yesterday, too. i reminded very much, if you look at quite similar parallel cases between abdulmutallab and richard reeve, space some years apart, -- richard reed, spaced some years apart, each trying to do harm to a transatlantic flight, using it is similar

chemicals, decisions were made by the previous administration, after looking at all of the factors involved, to enter richard reid into our civil justice system. i think he was indicted two or three days after the incident and is now spending life in prison in a super max facility in colorado. >> in this session yesterday, did the president ever tell those executives sitting around the table that there drop -- their jobs are on the line? >> i think the president was very clear in his 10-minute opening statement , to use his words, we screwed up. that this incident could have been a disaster. that that disaster was not

averted -- that disaster was averted by the brave citizens on that plane, not because the system worked as it should have. he did not find that acceptable. she will not find it finger- pointing among agencies to be something he will tolerate. i think he was very clear about the expectations in our accepting responsibility for what has happened and fixing it going forward. i think one of the reasons he will want to continue to look at the progress that we are making in addressing the problems that have been identified is to do exactly that -- have this process be economic one, to ensure that if someone takes responsibility for their aspect of the failing, that -- not just in a report that comes a couple weeks after, but a couple months after, the president, john

brennan and others will look back and see progress that has been made, not just in identifying but in moving forward to address those shortcomings. >> will the president replace the director of the united states secret service? >> it has not been discussed under any circumstance that i have heard it. i think he has great confidence in director sullivan, who has done a wonderful job in keeping he and his family safe. >> the president meets today with charlie rangel along with house democrats. is the president concerned about associating himself with it charlie rangel after he is involved in an ethics investigation, with his taxes? >> he is meeting with charlie rangel, george miller, nancy pelosi, committee chairs. among the three relevant committees in which health care

went through, i think everybody understands that as part of the openness of the debate we have had, that legislation had to go through the ways and means committee. >> a follow up. tom delay was house majority leader when the democrats criticized bush for appearing alongside him while he was under investigation. is this different? >> i do not see the analogy. >> the yemenis that went back from guantanamo to yemen in september and december of last year, where are they now? are they locked up some twhere? >> i can see what intelligence we have on them. >> can you say anything about -- what were the guarantees of security pertaining to them? >> i have not get into describing different or arrangements or agreements that we make in transferring to home countries or to third-party

countries as part of this process. >> can you say if an ultimate release is in a long-term plan for any of those? >> it for some reason the democratic caucus and the senate lost their 60 votes by a considerable margin, how might that change your legislative strategy? >> ha ha. you have taken me down a series of hypothetical so that would take me more than just a few seconds to wrap my head around. i am not entirely sure what we would get out of either my short-term or long-term answer. >> how important is the 60 votes to your legislative agenda? filibuster-proof senate. >> there are many answers for that, too. look, i will simply leave it at this. i think the president has outlined an agenda that he

believes addresses the problems that our country faces now and is based for quite some time. we are thankful to have 60 seats in the senate and i forget how many in the house to pass that legislative agenda. but i think to surmise what our strategy will look like, based on an election that is 11 months away, it is like predicting not who will win this super bowl but who will win the next super bowl. it would be nice to think about or play around with, but i do not know it would be based on anything specific. >> alabama. >> i would e-mail all my friends and alabama and tell them and good luck and i would read as hard as one possibly can for texas. -- root as i possibly can for -- root as i possibly can for taxes.